Monday, April 28, 2014

A few weeks ago I wrote about the recent disclosure of Medicare
payment data to the public. I finally got around to running my own
numbers from it, and found my total take was around $70,000.

Now,
normally I don't care how much other docs are getting. I try not to pay
attention to those things, as it's none of my business. But, due to a
recent news story, I decided to look up the stats on another doctor.

The
doctor in question is an interventional cardiologist, practicing in the northeast. His father is also a cardiologist, and they work together. Sounds nice huh? A family-run medical group.

Anyway, per the 2012 Medicare data, that year Uncle Sam paid this gentleman $313,375.23. DISCLOSURE:
I suck at math. Really. So this number could be completely wrong since I
had trouble making sense of which column was which, and then I had to
multiply across, then add.

Now, like I previously pointed out
this is gross, not net. Like all of us out there, I'm sure the good
doctor has insane office overhead to cover. This guy is in a field, unlike mine, where you truly are saving lives, and you can't put a price on that. And I'm also not in the
business of telling other people how to spend their money. After all, I blow most of my immense fortune on a Diet Coke habit.

Granted, this
wasn't all at once. It took him 4 visits over 10 days last November at Scores Gentlemans Club to
reach that amount, averaging $33,750 per visit. It was a cold winter, and I think we all needed to warm up (at the Grumpy household we cranked the heater up and got out extra blankets). Perhaps it was national "Support your local strip bar week" (if it was, I missed the memo).

I haven't been to
a strip bar since a bachelor party in residency, but don't think I
could spend that much on drinks, tips, and lap dances if I
tried (although I haven't tried, either). Maybe I wasn't going to the right bars.

But it gets better. The
good doctor (Zyad Younan, M.D.) put the charges on he & his dad's business credit card. Can you imagine how proud the elder doctor Younan
felt when the AMEX statement came in? "EKG supplies, ultrasound gel...
$135,000 at The Boob Palace? ZYAD!!!"

Regrettably, daddy's reaction to his prodigy's spending habits hasn't been in the news. He probably grounded him and took away the car. These things don't look very good on IRS audits.

I'm
really not sure how Dr. Younan, Jr. was planning to claim this as a business
expense. Granted, he's a heart doctor, and the heart is located in the
chest, and I'm sure there are a lot of chests displayed at Scores.
Perhaps it was a research project he was working on ("I want to put my stent in your vessel"). He could also have been
recruiting a new partner, though not necessarily for the practice.

"You say it's a study to repeatedly check my femoral artery pulse?"

So, to recap thus far: a successful cardiologist blew $135,000 in 4 visits at a strip bar, using his business AMEX.

But wait, that's not all!

As
anyone who owns a credit card knows, sooner or later the card company
wants to get paid (they're funny like that) and sent a bill to Dr.
Younan. Like any honest, law-abiding, boob-ogling, dad-fearing
cardiologist, he should pay it, right? And, if he had, none of this would even have made the newspapers.

But he didn't.

Instead, he claimed that he didn't have to pay because he was drugged. EACH TIME (I assume he means something beyond alcohol) and therefore has no recollection of being there.

Now, this, in my opinion, is pretty far-fetched. Okay, maybe once is semi-believable. I mean, stranger things have happened. One minute you're walking out to the doctor's lot, the next you're waking up and finding out you spent a fortune at a strip club. Maybe it was aliens. Or terrorists. Or your ex.

BUT 4 TIMES? I mean, that's one seriously good drugging job. If I'd blown that kind of money in a strip bar, I'd at least like to remember what I got for it. But not this unfortunate fellow. Whatever they used to drug him must have been pretty strong to make him not only forget, but to return to the same place 3 more times. Holy déjà vu, Batman!

"It's February 2nd, and I've been drugged by a stripper. Again."

The good doctor's refusal to pay is so steadfast that Scores has filed suit against him for the amount. They claim to have video of him in their fine establishment, acting, I assume, somewhat coherently. To date I haven't seen it listed on Youtube.

So, in summary:

1. No matter what Medicare actually pays your doctor, IT'S NOT WHAT THEY'RE TAKING HOME. The overhead for a medical practice is higher than you think. Probably much higher.

2. Don't let that hair-netted lady who puts out the bagels in the doctors lounge slip something into your coffee. You never know where you'll end up, sometimes repeatedly.

3. If you want to go to a strip bar, more power to you. But trying to charge it to your dad's business AMEX card may not be a good idea.

4. What you do with your hard-earned money is up to you, but remember to pay the bill. Because if you do, they won't sue you to get their money, and this sort of thing won't end up in the news.

5. $135,000 is a helluva lot of money to blow at a strip bar. I think my record was $50 for my share of the bachelor party.

Wednesday, April 23, 2014

Mr. Larsson is sitting in the lobby, reading old issues of People, during his wife's appointment. Suddenly he walks up to Mary's desk, holding a small plastic box.

Mary: "Can I help you, sir?"

Mr. Larsson: "Do you have a land-line?"

Mary: "Yes."

Mr. Larsson: "I need to make a call, and can't use a cell phone."

Mary: "Okay, that's fine, just come around the counter there."

He sets the plastic box on the counter, comes over to the desk, and starts unbuttoning his shirt.

Mary: "What are you doing?"

Mr. Larsson: "I need to send a pacemaker report to my cardiologist's office, and we don't have a land-line at home."

He tosses his shirt on a chair and starts attaching clips from the box to his chest.

"Wanna see the scar?"

Mary: "Um, I don't know how to send a pacemaker report..."

Mr. Larsson: "Can you unplug one of your phone lines and hand me the cord?"

Mrs. Larsson and I finish her appointment. She opens my office door and walks up front.

Mrs. Larsson: "ARNE! PUT YOUR SHIRT ON!"

Mr. Larsson: "But I need to..."

Mrs. Larsson: "NO! I told you, we'll stop at Dr. Senning's office tomorrow, and you can do it directly. You don't need to do this today!"

Mr. Larsson: "But Dr. Grumpy has a land-line!"

Mrs. Larsson: "So does Dr. Senning! Here's your shirt! I'm sorry, Mary, he's just very obsessive about this."They leave. The door closes. Mary and I stare blankly at each other for about 10 seconds. Then collapse in hysterics.

This past Saturday morning I was dragged in kicking and screaming consulted at the hospital to see an elderly gentleman. He'd fainted while playing bingo at the Mishwauketomee casino the previous night.

Dr. Grumpy: "What happened, sir?"

Mr. Bingo: "I just wanted to get out and do something. Ever since my wife died all I've done is stay at home endlessly and stare at the walls. I just couldn't take it anymore, and wanted to get out. So I went over to the casino."

Thursday, April 17, 2014

Last week, for those of you who are keeping score, the government released its list of how much Medicare pays doctors. The total for 2012 was...

(drumroll)

$77 billlion dollars.

If you like zeroes, that's $77,000,000,000.

"Are you sure? That's a lot of zeroes."

Now, there are roughly 850,000 docs out there who take Medicare. Which means (on average) each of us is getting $90,588.24 from Uncle Sam (this is ONLY Medicare, not other insurance companies).

Of course, that isn't even close to the truth. The released data also shows that 2% of the doctors out there are getting 25% of the take. So for those 2%, they're each getting $4,529,411.76.

As I'd expect, none of those guys are neurologists. And the last number (as big as it is) is peanuts compared to what your average insurance company or hospital CEO got as a Christmas bonus alone.

"My kid found these. We didn't know what else to do with them."

So which docs are getting the big Medicare money here?

1. Hematology/Oncology

2. Radiation Oncology

3. Ophthalmology

4. Rheumatology.

WOW! Those guys must be rich!

Nope, that's not it either.

Figures are misleading. While I believe in transparency, the raw numbers can be manipulated easily to make them show pretty much what anyone (usually a politician) wants.

That giant government payout is, in large part, what they're getting for supplies. These specialties have a few things in common:

1. They're primarily office based.

2. They have high overhead costs.

3. The first three are at high risk of being sued.

4. The first 2 are dealing with horribly sick patients, which cost more money to take care of.

I'm sure you're saying "why isn't neurosurgery on the list?" The office-based cost is the main reason. Most of their good work is in a hospital, and the facility supplies the medical equipment, drugs, staff, and operating room. The surgeon, like me*, shows up and brings her expertise (and the charges for it) with her, but the rest of the costs (and billing for them) get paid to someone else.

*That noise you hear is the horrified inhalation of neurosurgeons because I just mentioned them in the same sentence as neurologists.

So, okay, the oncologists must be rich.

Of course they are! They're part of the secret government-medical conspiracy that's making you smoke tobacco and eat horribly unhealthy food against your will, causing you to get cancer and need their services.

Get real. Yes, they're getting reimbursed a decent chunk of change. But that's gross, not net. Most oncology practices have an office infusion suite to do chemotherapy. This is done there because it's more convenient for the patient, and a helluva lot cheaper for the insurance, to do it in an office than a hospital. But cheaper is a relative term.

Let's look at drugs. One commonly used for breast cancer is Herceptin. This is given once a week, and the list price is $3344 per vial. Another one, Neupogen, is $310 a pop. There's a lot of them like that.

Yeah, but the doctor must charge, like, 2 or 3 times that amount, right? That's why they're rich!

Keep dreaming. You can charge whatever the fuck you want. Medicare will only pay you 106% of the MSRP. Which means, for that $3344 vial of Herceptin, you'll get roughly $3544 back.

So? The doctor is still getting a $200 profit on each vial! That's a lot, you greedy bastards!

Stuff it. Consider the following:

Infusion nurse: $40/hour + benefits.

Infusion chairs: $1500 each.

Mayo stand (a metal table, has nothing to do with condiments): $110 each.

TV set and cable subscription (the patients need something to watch for a few hours)

Wheeled medical stool: $50 each

Then you get into bags of saline, IV tubing, needles, phlebotomy equipment, band-aids, gauze, other medications (Zofran, Benedryl, Phenergan)... you get the idea.

And all of that comes out of the Medicare payments. Of course, the raw number doesn't mention that key point at all.

"And another thing..."

Another point: like many docs these days, the oncologist may have an NP or PA seeing patients. Of course, that person is likely working under the doctor's billing ID (called an NPI). So if both of them get, say, $100,000 back from Medicare, it's listed as money that ONLY went to the doc. And what you're seeing doesn't take into account the salary, benefits, and malpractice coverage for the NP, not to mention all the office supplies and support staff.

Wait, so you mean the money meant for 2 or more people can show up in the Medicare data as being all paid to one doc? Exactly. Doesn't give you a clear picture, does it?

The other fields are similar. Radiation oncology? A radiation machine will easily set you back a few million bucks. Not quite the same as say, a sofa from Penny's. But it's necessary in this line of work, because you can't practice without it (trying to irradiate tumors with the stuff you scraped off your kids glow-in-the-dark Halloween costume isn't helpful).

Then you need trained techs to operate it. Federal licenses and certifications to handle radioactive equipment. And a company that supplies/disposes of used isotopes (selling them to Al-Qaeda is frowned upon).

Ophthalmology? Have you ever been to one's office? They don't have something as simple as my Queens Square reflex hammer ($14 on Amazon). The gadgets they use are big, and to fully outfit a decent ophthalmology office will run you $100,000 to $200,000 - before you can even start seeing patients. Having your cataracts done? Each lens costs the doctor from $1000 to $3000 depending on what you need, not including all the other supplies needed for surgery. So a lot of the money is going to cover those expenses, too.

Rheumatology, like oncology, deals with some pricey drugs. Remicade, for example, is $915 a vial from the company.

Then, for ALL doctors, you have to figure in the other office expenses: computers, printers, chart system, staff, office furniture, office machines, paper, pens, coffee maker....

Yeah, but you guys get most of your office supplies free from drug reps! Sorry, Charlie. That practice was banned in 2008. Now the only thing reps can give us is samples, patient education brochures (which I throw away), and a hurried lunch of tuna sandwiches.

Office space alone can eat you alive. Between Pissy and I we have 2100 square feet. And we're paying $5100 a month for that. That's likely more than your mortgage payment for a house of similar size. And our office doesn't have a pool or wet bar.

Malpractice insurance? For non-surgical fields it's anywhere from $30,000 to $100,000 per year (or more). Surgeons? $100,000 to $300,000 (and up) per year depending on the field. That comes out of your share of the $77 billion, too.

Then, when you finally collect your money, a billing company will get 5% to 10% of it.

So, this is not exactly a high-profit-margin field (medical students: GET OUT NOW). A pretty big chunk of the Medicare money goes to cover just the overhead. Running a medical practice is not something you want to do by cutting corners. When things go wrong, they can go VERY wrong.

I'm not looking for sympathy. I'm just trying to make the point that numbers like this are misleading, and can be twisted to mean whatever anyone wants them to. But when you see how much your doctor is getting for taking care of you, that's not all going in his/her personal pocketbook.

Far from it.

But that doesn't stop me, and most of us, from doing our best to care for you, every single day.

Tuesday, April 15, 2014

Miss Poppy: "Wait, first, I need to know if you guys are connected to that big database where you can see which of your patients are getting narcotics from other doctors and when and how many and all that stuff."

Monday, April 14, 2014

"It's been a busy year. I had to have all kind of treatments from the eye doctor. A few months ago I had this weird feeling in my eye, and had my friend Jan look at it. She's a librarian at the kids school, so I figured she reads all kinds of stuff. She thought maybe I had a fungus in my eye, and I'd once heard of a guy that happened to on the news, so it seemed like I should treat it. My oldest boy is on the high school football team - they were in the state playoffs last year if you remember - and is always having jock itch with burning and red stuff in his crotch. He has these tubes of fungus cream for it in his bathroom, so I rubbed it in my eye for a few days, but that only made things worse. So I went to the eye doctor and he said the cream wasn't supposed to go in my eye because it damaged something and I had to have all kinds of treatments for it. It really ticked me off because you'd think Jan should know better."

Tuesday, April 1, 2014

It's been 4 years since I last ran this piece, and I think it's worth putting up again.

It ain't much to look at.

Two, maybe three pounds of
grayish-white goop. It's not even solid in a living person. More like
Jello that floats around in it's vault.

But it's
amazing. From that sloppy goop has come remarkable stuff. It's sent a
robot to land on a moon of Saturn. It's explored the bottom of our
deepest oceans. Built the Taj Mahal. The Great Wall of China. Painted
the Mona Lisa.

Go listen to the remarkable Bach's
"Toccata and Fugue in D minor". Not just the famous opening 30 seconds
or so, but the whole 9-10 minute thing. That all came from the goop,
long before it was heard or played on an instrument, it was just a
series of electric signals jumping from nerve to nerve. The piece is
over 300 years old. The mind that created it has been dead for over 250
years. And humans will likely be listening to it long after my
great-great-great-grandchildren are dust.

The soul is
there. The heart is amazing, but for all our romantic beliefs about
it, who we really are is floating around in the goop. It's where hate,
love, and everything in between comes from.

It's
capable of terrible evil, such as the Holocaust, and remarkable good.
Look at the outpouring of altruism that follows disasters. I love my
dogs, but if something bad happens to a dog on the next street, they're
not going to care. Yet the goop wants to help people who we've never
met and have no direct impact on our own lives

My
regular readers know I'm interested in maritime history. Why? I have no
idea. It's just been a subject I've loved as long as I can remember.
I've never been in the navy. The family military history consists of
grandparents who served in the army, but never were sent overseas. I can
only assume there is some particular molecular structure in my goop
that makes me interested in it. Or that made me want to treat other
people's goop for a living.

Twin and biological studies
have shown that most of who we are is how we came here. Yes, life
experiences and background count for something, but the goop is most of
it. People with conservative beliefs raise kids who turn out to be
liberals, and vice versa, no matter how hard they may try to pass on
their beliefs.

Coke vs. Pepsi. Dogs vs. Cats. Mac vs.
Windows. I suspect whatever makes us fall on one side or the other of
these great philosophical issues is 95% or more in the goop, and we
just come that way.

Everything you are, have been, and
will be. Have desired, dreamed of, and done. Have felt. It all comes
from a few pounds of goop.

And this fascinates me.
Because, let's face it, we're just another part of the planet. A
collection of complex molecules, electrical impulses, and chemical
reactions. That's all people. Anatomically, all humans are pretty much
the same. And we're not that different from other mammals. The
difference in our genetic sequence vs. that of a mouse ain't much.

And
yet that small amount of difference has led to amazing results. The
ability to think beyond our own biological needs and to see the world
around us for the beauty it contains. To watch a sunset and be in awe,
even though we understand the science behind it. And to look up at the
night sky, and wonder.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

Singing Foo!

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Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.